Discharge Medications: CHPSO Safe Tables Report

Ensuring discharged patients have access to and take their medications affects readmissions and patient safety significantly. Medication reconciliation is a key component of this. Medication adverse events have been estimated to occur in approximately 20 percent of patients following discharge, and of those, two-thirds were determined to be either preventable or ameliorable.(1,2) Given the number of US discharges, this represents 4 million patients a year having an ameliorable or preventable drug related adverse event.

The Joint Commission’s medication reconciliation National Patient Safety Goal (NPSG) was introduced in 2005 and followed by Sentinel Event Announcement #35. The current NPSG states “Medication reconciliation is intended to identify and resolve discrepancies—it is a process of comparing the medications a patient is taking (and should be taking) with newly ordered medications. The comparison addresses duplications, omissions, and interactions, and the need to continue current medications. The types of information that clinicians use to reconcile medications include (among others) medication name, dose, frequency, route, and purpose. Organizations should identify the information that needs to be collected to reconcile current and newly ordered medications and to safely prescribe medications in the future.”

During recent CHPSO safe tables clinicians discussed medication reconciliation. There are two main components to medication reconciliation: compiling the medication history and managing the patient’s medications. The skills needed for medication history compilation and medication management differ, and, while medication history is important at each transition, medication management becomes paramount at certain transitions, such as discharge. The quality of admission medication reconciliation affects medication reconciliation at discharge. Errors not caught early may propagate throughout to discharge.

So, who is doing medication reconciliation? Most facilities report that they use a combination of nurses, pharmacy technicians and pharmacists to compile the medication history, but medication management, assuring that the medications and doses are appropriate for the patient, is done by a pharmacist or physician. Facilities report a pharmacy technician can obtain 10-20 medication histories during a shift and that a pharmacist can see about 5 patients a day.

Medication reconciliation can be a time-consuming process, especially for complicated patients, patients with low health literacy and patients with no or limited English. Many sources are used to identify what medications the patient is actually taking including: the patient, family, friends, retail pharmacies, other health care facilities, dialysis centers, methadone clinics, pharmacy benefit managers and, for controlled substances, state Prescription Drug Management Programs (PDMPs). In California, the state PDMP is CURES (Controlled Substance Utilization Review and Evaluation System).

In addition to updating the medication list in the Electronic Health Record, some pharmacists are writing chart notes so that information is readily visible to physicians and can be referred to if the patient is re-hospitalized down the road. Communication is especially important when therapeutic interchanges or substitutions have taken place.

Comprehensive medication management may be inhibited by concerns about making changes to medications prescribed by other facilities and other providers, whether it is the current physician’s lack of expertise in the disease the medication is used for, lack of clarity about the reason for the medication or reluctance to change another provider’s treatment plan.

Ideas to improve medication safety were also discussed at the safe tables. Several facilities offer videos in addition to the more traditional one-on-one medication education or handouts. Patients who are considered high risk or who are taking certain high risk medications are more likely to get some education about their medications prior to going home, if there is a care coordination program in place. At discharge the patient may or may not receive discharge education or counseling based on a wide variety of factors, but they are required to be given discharge paperwork. Unfortunately, medication information may get buried in the stack of paper.

Several facilities reported that they are teaming up with local retail chains to provide in-hospital bedside delivery of discharge medications to improve medication adherence and reduce readmission. This is particularly useful in rural areas where 24/7 pharmacies may not be available. Some facilities are trying follow up calls or post-discharge visits to make sure patients could get their medications filled and are taking them appropriately.

Some facilities have tried giving patients pocket cards, but note they get outdated quickly. These medication lists must be robust enough to handle both prescription and over-the-counter medications. They also need to be able to include comments from patients and providers as to why medications are or are not being taken. Several companies have tried to help patients and providers keep medication lists up-to-date, but portability has always been an issue.


Forster AJ, Murff HJ, Peterson JF, et al. The incidence and severity of adverse events affecting patients after discharge from the hospital. Ann Intern Med 2003; 138:161.

Forster AJ, Clark HD, Menard A, et al. Adverse events among medical patients after discharge from hospital. CMAJ 2004; 170:345.